MEDICARE: KASSONDRA MAE VERHOFF ATC, AT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246Z00000X	Other Specialist/Technologist	AT.005074	OH
2	390200000X	Student in an Organized Health Care Education/Training Program	AT.005074	OH

General Provider Information

NPI Number	:	1013462357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASSONDRA MAE VERHOFF ATC, AT

Provider Business Mailing Address
First Line	:	12012 TOWNSHIP ROAD 53
Second Line	:
City	:	MOUNT CORY
State	:	OH
Zip	:	45868-9633
Country	:	US
Telephone Number	:	567-208-8401
Fax Number	:

Provider Business Practice Location Address
First Line	:	4025 INDIAN RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43606-2226
Country	:	US
Telephone Number	:	419-531-1693
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2016
Last Update Date	:	08/16/2016

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